With the recent content changes to the USMLE® Step 1 and Step 2 CK exams, it became clear that students will face an increased number of questions assessing communication skills, system-based practice, patient safety, legal and ethical skills, and professionalism. However, there is one significant element of this announcement by the NBME® that has been lost in the chatter surrounding these "new focus areas": that purely ethics-related questions and patient safety-related questions will not be tested on Step 1.
The patient safety and ethics questions will be reserved for the Step 2 CK exam. Instead, Step 1 will see an increased focus on questions testing communication and interpersonal skills.
Evidence of the changes
How do we know this? Well, despite there being no official announcement from the NBME, there are a number of recent signifiers that point towards the content of the exam. Firstly, it’s actually reflected in the USMLE Step 1 content outline. As you can see below, the outline of social sciences questions (which amass to 6-9% of questions) does not feature ethics or patient safety; only communication and interpersonal skills.
| System | Range, % |
|---|---|
| General Principle | 12–16 |
| Blood & Lymphoreticular/Immune Systems | 7–11 |
| Behavioral Health & Nervous Systems/Special Senses | 9–13 |
| Musculoskeletal, Skin & Subcutaneous Tissue | 6–10 |
| Cardiovascular System | 5–9 |
| Respiratory & Renal/Urinary Systems | 9–13 |
| Gastrointestinal System | 5–9 |
| Reproductive & Endocrine Systems | 9–13 |
| Multisystem Processes & Disorders | 6–10 |
| Biostatistics & Epidemiology/Population Health | 4–6 |
| Social Sciences: Communication and Interpersonal Skills | 6–9 |
Step 1 Test Specifications Chart. From "USMLE Step 1 Content Description." Copyright © 1996-2021 Federation of State Medical Boards (FSMB) and National Board of Medical Examiners® (NBME®).
Where you will find ethics and patient safety questions is in the social sciences section (10-15%) of the USMLE Step 2 CK content outline.
| System | Range, % |
|---|---|
| General Principles of Foundational Science | 2–4 |
| Immune System | 3–5 |
| Blood & Lymphoreticular System | 4–6 |
| Behavioral Health | 6–8 |
| Nervous System & Special Senses | 6–8 |
| Musculoskeletal System/Skin & Subcutaneous Tissue | 6–10 |
| Cardiovascular System | 8–10 |
| Respiratory System | 7–9 |
| Gastrointestinal System | 7–9 |
| Renal & Urinary System & Male Reproductive | 4–6 |
| Pregnancy, Childbirth & the Puerperium | 4–6 |
| Female Reproductive System & Breast | 4–6 |
| Endocrine System | 4–6 |
| Multisystem Processes & Disorders | 4–6 |
| Biostatistics & Epidemiology/Population Health/Interpretation of Medical Literature | 3–5 |
| Social Sciences: Legal/Ethical Issues & Professionalism/Systems-based Practice & Patient Safety | 10–15 |
Step 2 CK Test Specifications Chart. From "USMLE Step 2 CK Content Description." Copyright © 1996-2021 Federation of State Medical Boards (FSMB) and National Board of Medical Examiners® (NBME®).
Furthermore, the updated version of the official USMLE Step 1 Sample Test Questions contains wording in line with these changes. Reports from recent Step 1 exam-takers have also confirmed a lack of ethics and patient safety questions on their tests.
What this means for your Step 1 exam prep
As this is a relatively new content change, you are likely to read a lot of opinions online or have discussions with other students about it in the near future. When these conversations arise, we recommend that you be assured in your knowledge that the distinction between the new content on Step 1 and Step 2 CK is reflected in the NBME’s own content descriptions, as outlined above.
It’s worth noting that a lot of the current textbooks and exam-prep resources haven't yet adapted their content distribution to align with this new exam focus. It’s important to keep this in mind to avoid spending valuable study time on topics or difficult questions that won’t appear on the exam
Here at AMBOSS, our medical editors have been working quickly and thoroughly to update our content to reflect these changes. This means that you can continue to prepare for Step 1 with AMBOSS and not waste a single moment on questions that you won’t be tested on.
Our update includes a thorough upgrade of our article on Patient communication and counseling. Be sure to read it on AMBOSS before your Step 1 date so that you are well prepared for these new focus areas.
When preparing, there is one important caveat to keep in mind: while direct ethics questions will no longer appear on Step 1, it’s still possible that an ethically challenging scenario will be presented in the vignette for a question that then asks about communication and interpersonal skills.
Combined with the move to pass/fail, it’s not unreasonable to feel as if the Step 1 exam is in a state of flux. However, there’s no need to worry. Maintaining your study schedule and resolving to have a strong fundamental understanding of Step 1 topics will ensure your success. And, as Step 2 CK scores are likely to become much more important in the future, it’s important to have a really good grasp of the content now so you’ll be confident when it’s time to take Step 2. You can find some great tips on preparing for Step 1 as a pass/fail exam in Dr. Ryan Colaço’s blog post here.
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